Central Line
NEJM video guide
Indications
- Extracorporeal therapies: HD, CRRT, Plasma (PLEX) or RBC exchange transfusion
- Venous access for: vasopressors, chemotherapy, parenteral nutrition, hemodynamic monitoring (CVP, ScvO2) cardiac parameters (via PA catheter), inadequate peripheral access
Relative contraindications
- Increased bleeding risk, anatomic distortion at site selection, indwelling vascular hardware (pacemaker, HD access), vascular injury proximal to site, skin infection overlying selected site
Consent
- Immediate complications: bleeding, malposition, arterial puncture, arrhythmia, pneumo- or hemothorax, air embolism, damage to surrounding structures (nerves, thoracic duct)
- Delayed complications: infection, thromboembolism, myocardial perforation, venous stenosis
Pre-procedural considerations
- Bleeding risk guidelines: Plts > 20k, INR < 3
- All pts need to have telemetry & pulse oximetry monitoring
- A R PICC doesn’t mean you cant do RIJ central line; you can’t have more than one line at a site, but you can have more than one line in a vassel.
- With every pt, consider LENGTH, LOCATION, LUMENS, and LINE TYPE!
Central Line |
Recommended Length (for pt height >5’5”) |
|---|---|
| Right IJ or Subclavian | 15 cm |
| Left IJ or Subclavian | 20 cm |
| Femoral | 25 cm |
| *Confirm length of catheter in your kit before you open/place the line! | |
Type of Line |
Uses |
Special Considerations |
|---|---|---|
| Triple Lumen (7Fr) | Central access for vasopressors, caustic infusions | Consider lumens needs; triple lumen is most versatile but can warrant dual lumen |
| MAC or Cordis* | ‘Short and fat’ allowing rapid transfusion; MAC has two parts and can float a PA catheter through it | MAC is placed with dilator still in introducer |
| Dialysis Catheter (Trialysis, 12 Fr) | Dialysis line with two 12 Ga. Lumens for dialysis with a third 17 Ga. lumen for added access | Two serial dilations |
| *Can place triple lumen in MAC for additional ports; lose ability to rapidly transfuse | ||
Site |
Advantages |
Disadvantages |
|---|---|---|
| Internal Jugular Vein | Minimal risk of PTX; improve target with positioning and use of US; easily compressible if bleeding occurs | Risk of carotid puncture, difficult in obese pt; vein collapsibility with hypovolemia |
| Subclavian | More comfortable for pts; landmark driven approach; lowest risk infection | Increased risk of PTX, harder to control bleeding with pressure, technically more difficult |
| Femoral | Easiest to access, no risk of PTX, can be placed during CPR and intubation | Very Difficult in obese patients (pannus); target vessel is shorter (before branching) and deeper than IJ; should be done under inguinal ligament to prevent retroperitoneal bleed vs compressible leg bleed. |
Procedural considerations
- Cap side ports with blue claves (not included in Trialysis kit) prior to flushing
- For IJ access, place pt in slight Trendelenburg position to engorge vein
- While advancing needle, ensure constant negative pressure with aspiration of plunger and visualization of needle tip with US
- Designate someone to watch tele while threading guidewire to monitor for arrhythmias. Limit guidewire insertion depth to no more than 16 cm to reduce arrhythmia risk
- Always ensure guidewire is secured while it is inside a vein
- Always ensure target for venous cannulation is visualized and guidewire is placed correctly prior to dilation:
- Compression of target vessel
- Non-pulsatile dark blood return (unless on 100%FiO2, may be brighter red)
- US visualization or needle and wire
- Can use pressure tubing and angiocath to confirm CVP or obtain venous O2 sat.
Supplies
- Table
- Sterile gloves and gown
- Mask, hair covering, and eye protection
- Ultrasound with linear probe
- Ultrasound cover (check length; shorter ones may not reach sterile field)
- Chlorhexidine x3
- Central line kit, which typically includes:
- Lidocaine, syringe for lidocaine, small gauge needle to deliver lidocaine
- Full body drape
- Skin prep solution
- Syringes
- Scalpel
- Sterile gauze
- Catheter, dilator, needle, wire o Suture and needle driver
- Saline flushes (note that while the saline is sterile, the plastic syringes are not); the saline will need to be transferred to an empty reservoir in the kit; and then utilized using sterile syringes included in the kit
- Blue claves to cap side ports x 3; for dialysis access, ClearGuard antimicrobial caps are preferred
- Optional items:
- Back up or larger sterile dressing (the ones in kit might be too small or dropped)
- Micropuncture kits for added safety in case of arterial puncture, especially during high bleeding risk cases
- Lidocaine with epinephrine if high bleeding risk
- Backup guidewire
- Small tegaderms to secure edges of full body drape
Procedural considerations
- Timeout with nursing prior to starting
- Double check that the correct type & size of catheter kit has been selected for the target site (for instance, triple lumen catheters typically only have one size; but dialysis catheters have varying lengths)
- For all ultrasound guided procedures, try to position the machine such that the direction of needle insertion will face the screen
- Numb patient immediately after draping, prior to set up to allow time for lidocaine to work. Complete both subcutaneous skin wheal as well as deeper lidocaine administration with ultrasound guidance. Note that deeper numbing is not without additional risk – it may be more painful to try to locate your needle on ultrasound to numb safely than to just pursue venopuncture.
- Set supplies up in exactly the order of use to ensure all are present and functioning (and to create space; for instance, suturing/dressing to the side)
- Cap side ports with blue claves prior to flushing, leaving the middle/longest port uncapped for passage of the guidewire
- It is very important to make sure side ports are clamped, especially during dialysis catheter placement (since the side ports are typically not capped during insertion)
- Flush all ports
- For IJ access, place pt in slight Trendelenburg position to engorge vein
- While advancing needle, monitor for successful venopuncture both through visualization of the needle tip on US but also through continuous aspiration of the syringe plunger
- Designate someone to watch telemetry while threading guidewire to monitor for arrhythmias; limit guidewire insertion depth to no more than 20cm to reduce arrhythmia risk (15cm to 20cm is reasonable especially if LIJ or femoral). I think 15 to 20cm is reasonable, especially if LIJ or femoral; also take into account that learners often accidentally pull out a bit of the guidewire during dilation; also consider saying how many hash marks along with of cm (each hash mark is 10cm), for instance “do not progress the guidewire beyond two hashmarks” - once a guidewire is intravascular, always ensure someone is holding onto it; there is a risk of accidently pushing it in / pulling it out during preparations for next steps
- Prior to dilating, confirm wire is in target vein with ultrasound (in short and long axis). Long axis might show through-and-through, distal to site of wire entry
- Always ensure target for venous cannulation is visualized and guidewire is placed correctly prior to dilation:
- Compression of target vessel
- Non-pulsatile dark blood return (but be cognizant this is unreliable in patients in shock)
- US visualization of needle and wire
- Can use pressure tubing or the empty guidewire sheath or angiocath to confirm CVP (check if blood continuously rises against gravity and/or is pulsatile in tubing) or obtain venous O2 sat.
- See Youtube video above for complete steps of procedure
Post-procedural considerations
- Every IJ or subclavian central line needs a confirmation CXR to confirm no PTX
- Ideal placement of distal tip: in SVC just outside the right atrium, approximately near/ superior to carina and right tracheobronchial angle
- For dialysis access, tip at the CA junction is favored for highest flow rate
- Troubleshooting complications:
- Arterial Access or puncture: immediately remove needle and hold pressure for 15 mins to prevent hematoma formation; if uncontrolled bleeding or artery was dilated, STAT Vascular Surgery consult
- Bleeding: place direct pressure; subclavian access precludes ability to compress and confers highest bleeding risk; if uncontrolled, STAT Vascular Surgery consult
- Pulmonary complications: if free air aspirated into syringe, consider PTX vs. poor seal of syringe and needle. STAT CXR. If rapid deterioration, needle decompression and chest tube placement required
- Venous air embolism: Can occur if air introduced to system during placement, flushing, or if left open to the atmosphere. If suspected, place pt in left lateral decubitus position to trap air in right apex and place pt on 100% O2 to speed resorption
- Arrhythmia: Immediately withdraw wire to lesser depth. If arrythmia persists, abort procedure, treat pt, and determine cause.
Troubleshooting complications
- Arterial Access or puncture: immediately remove needle and hold pressure for 15 mins to prevent hematoma formation (US can be used to detect persistent hemorrhage); if uncontrolled bleeding or artery was dilated, STAT vascular surgery consult
- Bleeding: place direct pressure; subclavian access precludes ability to compress and confers highest bleeding risk; if uncontrolled, STAT vascular surgery consult
- Pulmonary Complications: if free air aspirated into syringe, consider PTX vs poor seal of syringe & needle. Close attention to pulmonary complication & STAT CXR to assess PTX. If rapid deterioration, needle decompression and chest tube placemen required
- Venous Air Embolism: can occur if air introduced to system during placement, flushing, or if left open to the atmosphere. Effects are variable, but if suspected, place pt in left lateral decubitus position to trap air in right apex and place pt on 100% O2 to speed resorption
- Arrhythmia: rationale for telemetry monitoring as guidewire can lead to atrial or ventricular arrhythmias; immediately withdraw wire to lesser depth; if arrythmia persists, abort procedure and treat patient and determine cause
- Resistance to guidewire/dilator: it is not unusual to experience mild resistance during guidewire insertion, especially as more length is introduced or the needle was introduced too perpendicular to skin; but firm resistance is concerning for not being endovenous, stenosis, or thrombus. consider retracting and reintroducing; or abort and try again with finder needle to ensure correct site insertion; never forcefully advance wire or dilator